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Full text of "NAVY MEDICINE Vol. 80, No. 6 November-December 1989"

NA VY MEDICINE 



November-December 1989 




Surgeon General of the Navy 

Chief, BUMED 

VADM James A. Zimble, MC, USN 



NA VY MEDICINE 



Deputy Surgeon General 

Deputy Chief, BUMED 

Chief, Medical Corps 

RADM Robert W. Higgins. MC. USN 



Public Affairs Officer 

CAPT Charles W. KJee. USN 

Lditor 

Jan Kenneth Herman 

Assistant Editor 
Virginia M. Novinski 

Editorial Assistant 
Nancy R. Keesee 



S\ 



Vol, 80, No. 6 

November- December 1989 



Department Rounds 

2 Flight Surgeon's Heart and Hands Go Out to Villagers 
LCPL S.E. Savage, USMC 

5 Navy Environmental Health Center Dedicates New Facility 

Features 

6 Dr. Dinsmore's Souvenir 

CAPT H.H. Dinsmore, MC, USN (Ret.) 

10 Total Quality Management: Mandate for Change 
CDR W.J. Lambert, Jr., MSC, USN 
LT R.P. Beaudoin, MSC, USN 



V.-fl'} UfJilCISh. \o\ SO, Vr 6, (ISSN 0S9S-H211 USPS 

316-0701 is published bimonthly b\ the Department of I he \avv. 
Bureau of Medicine and Surgery I By MEDOOPl. Washington. 
DC 20372-5 1 20. Second-class postage paid at W ashington. DC. 
and additional mailing offices. 

POSTMASTER Send address changes in Sfctvj \frdtcine 
care oi NavaE Publications and 1 onus Center. AT I 
306. 5(01 Tabor Avenue. Philadelphia. PA 19120. 

POLICY: VVjt . Median* is the official publication of the 
Navy Medical Department, h is intended for Medical Depart- 
ment personnel and contains prolrssional Information le^ufvc 
to medicine, dentistry, and the allied health sciences Opinions 
expressed are those of theaulhorsand do not necessarily repre- 
sent the official position of the Department ol the Navy, the 
Bureau of Medicine and Surgery, or any other governmental 
depart ment or agency Trade names are used for identification 
only and do not represent an endorsement by the Department of 
'■ or the Bureau of Medicine and Surgery Although 
Atari \tedicin? may ciieore\iraclfromdirecUves. authority for 
action should be obtained from the cued reference. 

DISTRIBUTION: Atavr Mrdicint a distributed :* 
duty Medical Department personnel via the St*ndBfcJ Na.v 
Distribution List. The following distribution isauthori/ed: one 
copy for each. Medical. Denial. Medical Service, and Nurse 
Corps officer, one copy lor each 10 enlisted Medical Depart- 
ment members. Requests to increase or decrease the number at 
allotted copies should be forwarded to Wn UrJiime via ihu 
local command. 

Vj4l ) MEDICI \'t is published from appropriated fundsby 
authority of the Bureau of Medicine and Surgery in accordance 
sviih Nayy Publications and Printing Regulations P-35. The 
Secretary oi the Navy has determined that litis publication is 
necessary tn the transaciiun oi business required by law of the 
Department of the Navy Funds lor printing this publication 
have been approved h) ihe Navy Publications and Printing 
- es. letters, and address changes may be 
forwarded to the Editor, Airvi Vrdtcme, Deparimem of tbe 
Navy. Bureau of Medicine and Surgery (BL'MFD OOPl. 
Washington. DC 20372-5120 Telephone (Area Code : 
1315. 653-1297 Autoton 294-1315. 294-1297. Contributions 
from the Held are welcome and will be published as space 
permits, subject to editing and possible abridgment 

For ^ik S the Superintendent of Documents. L.5. Govern- 
ment Printing Office. Washington. DC 20402 



N'AVMFD P-50MS 



13 Medical Anthropology: A Prospective Role in Navy Medicine 
B.H. Grant 

17 Transportation of Litter Patients in USS Missouri 
CDR J. W. Smith. MC, USN 
LTM.C. Norcross, MC, USN 
LT S.W. Elwood, MC, USN 

Professional 

22 Dialytic Capabilities in the Operational Setting 
LCDR D.J. Connito, MC, USNR 
HMC W.J. Balko, USN 

24 Metal Fume Fever 

LT C. Armstrong, MC, USNR 
LCDR T.D. Almquist, MC, USNR 

Notes and Announcements 

15 Navy Nurse's Ambulatory Care Symposium 
21 Highlights From the Navy Medical Research 
and Development Command 

26 In Memoriam: RADM J.R. Lukas, MC, USN (Ret.) 
. . . HMCM S.W. Brown, USN (Ret.) 

27 INDEX Vol. 80, Nos. 1-6, January-December 1989 



COVER: In 1966, a Viet Cong mortar shell slammed into the chest of a 
South Vietnamese soldier. The removal of this live ordnance became 
the subject of one of the most dangerous and innovative combat sur- 
geries ever performed. Story on page 6. Photo courtesy CAPT Harry H. 
Dinsmore, MC, USN (Ret.). 




A look back: Navy medicine 1913 



BUMED Archives 




Naval Hospital, Puget Sound, WA 



November -December 1989 




Department Rounds 



Flight Surgeon's Heart and 
Hands Go Out to Villagers 



NAVY MEDICINE 




The line of Honduran people 
grew longer as they waited for 
free medical care at the Devalk 
Clinic, Soto Cano Air Base, Hon- 
duras. The lyrics of a popular Ameri- 
can song playing on the radio seemed 
surreally appropriate for the occasion: 
"I came here, for you to love . . . ." 

The heat of the day was thick and 
oppressive, yet the doctors, nurses, 
and medics worked at a furious pace. 
Treating each of the 200 sick or 
crippled indigents was a priority. 

(he medical staff, composed pri- 
marily of Army and Air Force person- 



Flight surgeon Dr. Richard Uruchurtu 
oversees the work of other medical per- 
sonnel during Exercise King's Guard. 



nel of the U.S. Joint Task Force- 
Bravo (JTF-B), U.S. Southern Com- 
mand, provided free medical services 
three times a week. The clinic aug- 
mented the relatively simple Hondu- 
ran medical practices. Because of a 
small U.S. staff, their treatment was 
limited to patients whose cases fell out- 
side the realm of Honduran medical 
expertise. Often, those cases prove to 
be the most shocking. 

"They've walked, crawled, or hitch- 
hiked through the stifling heat to be 
here. Why can't we work through these 
conditions?" seemed to be the thought 
driving the military medical staff. And 
work through it, they did. 

In one corner of an outdoor area at 
the clinic, a U.S. Navy physician spoke 
soothingly, in Spanish, to his elderly 
patient. He offered words of relief to 
the woman, whose festering ulcer had 
eaten a hole deep into her leg as he also 
gave instructions, in English, to the 
U.S. Army medic scrubbing her 
wound. 

"Scrub away that dead yellow skin," 
instructed LT Richard Uruchurtu, 
MC, "give the proud flesh under it a 
chance to heal. 

"I've had the experience, in the past, 
of being in Third World countries," 
said the 37-year-old Uruchurtu. "I've 
seen poverty and was somewhat famil- 
iar with impoverished conditions. I 
knew this would be very different than 
walking down the street in La Jolla 
fCA)," he continued. "But 1 suppose 
what caught me by surprise were the 
array and severity of the illnesses that 
plague this country. That. 1 hadn't 
seen." 

Uruchurtu attributed much of the 
country's medical problems to a lack 
of education about basic preventive 
medicine. He said soberly, "To the 
man with a wife and several children, 
it's more important to vaccinate his 
cows than to vaccinate his children. He 




An elderly patient winces as Dr. 
Uruchurtu treats her ulcerated foot 
(below). 




can always have more children," he 
went on. "but he can't always get 
another cow." 

Uruchurtu also blamed poor 
hygiene for many of the country's 
woes. "The combination of poor edu- 
cation, lack of running water, poor 
nutrition, and poor personal hygiene 



November-December 1 989 



serves to create life-threatening situa- 
tions out of basically simple condi- 
tions," he said. 

"Life is cheap here," he continued. 
"I've seen pain and suffering, but I 
haven't seen those conditions go on as 
long as they have here." The doctor 
saw things he had previously only read 
about in medical textbooks. 

Because of his affiliation with 
Marine Light Attack Helicopter 
Squadron 267, Uruchurtu spent 3 days 
a week with the JTF-B medical staff 
during the month he was in the coun- 
try. 

Uruchurtu worked well with the 
local Honduran people, perhaps 
because of his Basque/ Spanish herit- 
age, or maybe due to his humble begin- 
nings. "I didn't come from a jaded 
background," he explained with an 
ever-ready smile. Having a father 
who worked for the Federal Aviation 
Administration meant that his family 
relocated several times during his 
childhood. 

In 1973. at age 22. Uruchurtujoined 
the U.S. Air Force as a medic. From 
the beginning of his enlistment, he 
saved money and invested his spare 
time in a college education. "1 didn't 
have the means to put myself through 
college. 

"True to its word, the military had 
tuition assistance, educational 



programs, worldwide assignments, 
off-duty education courses, corre- 
spondence courses, and education 
offices. These were the tools I needed 
and used to carve out my future," 
Uruchurtu gratefully acknowledged. 
He spent 6 years in the Air Force, and 
by the end of his enlistment he had 
acquired his bachelor's degree. 

After his discharge in 1979, he 
embarked on a trail toward fulfilling a 
childhood dream — becoming a physi- 
cian. Uruchurtu was accepted to the 
College of Osteopathic Medicine of 
the Pacific (Los Angeles) before finish- 
ing his last year at graduate school at 
the University of New Mexico. A 
chance meeting with a Navy medical 
recruiting officer at a medical conven- 
tion encouraged him to once againjoin 
the military. 

After doing his internship at Okla- 
homa Osteopathic Hospital in Tulsa 
and flight training at Pensacola, he 
was designated a flight surgeon to 
work with the Marine Corps. 

King's Guard '89, the training exer- 
cise linking U.S. Marine, U.S. Navy, 
and Honduran Marine and Army 
forces, brought him to Honduras. 
Helping the JTF-B medical staff get 
hundreds of destitutes back to reason- 
ably good health wasa large part of his 
mission. While, maintaining the good 
health of his marines was his primary 



Dr. Uruchurtu fills out paperwork on a 
Honduran patient. 




purpose, the dire need of the natives, 
coupled with the severity of their con- 
ditions made their care slightly more 
pressing. "This is not typical Military 
Sick Call out here," he said, "it's not 
colds, sprained ankles, or athlete's 
foot. This is no kidding, real-world 
disease here. 

"I'm a physician," he continued, 
"and for me to be able to help people 
who are truly in need gives me feelings 
I can't put into words." As he spoke, 
the cry of a small child having blood 
drawn grew louder. "That child is beg- 
ging for her mother to burp her," he 
said, "that is the only way she has ever 
known to deal with pain." 

Uruchurtu strongly emphasized 
that he and his American colleagues 
were not in Honduras to replace its 
medical corps. "We are here to aug- 
ment their program and to train them 
in some modern basics. We are not 
here to belittle the good they're doing." 

The basic difference between Hon- 
duran and American doctors is not 
really in quality of people, said 
Uruchurtu, but in the technology and 
training available to them. "The best 
we can hope for down here is to get 
these people's wounds to a point where 
the body's defense system can begin 
fighting illness again and the Hondu- 
ran doctors can help maintain that sys- 
tem. The Honduran people can also be 
taught proper personal hygiene, and 
that's going on right now," said 
Uruchurtu. 

While in Honduras, Uruchurtu had 
high hopes of changing the lives of the 
people with whom he came in contact. 
There is little doubt that he did, given 
his gift for medicine and love for peo- 
ple. One other benefit from his work- 
ing with these people is apparent in 
Uruchurtu. The Honduran indigents 
have touched his life as well. 

"This, for me, was a professionally 
and emotionally enriching expe- 
rience," he beamed, "sometimes, when 
in garrison conditions, things get a lit- 
tle ordinary. Out here, it's anything 
but ordinary." □ 

—Story and photos by LCPL Steven E. 
Savage, USMC, Joint Public Affairs Office, 
MCAS. El Toro. CA 92709. 



NAVY MEDICINE 



NAVY ENVIRONMENTS HEALTH CENTER 




New 

Facility 

Dedicated 



The Navy Environmental Health 
Center's (NAVENVIRHLTH- 
CEN) long struggle to establish 
a permanent home came to an end. On 
17 July 1989, the Center formally dedi- 
cated a new facility in an office com- 
plex adjacent to the Norfolk, Virginia 
International Airport. 

The building dedication ceremony 
was the culmination of an evolution- 
ary process for NAVENVIRHLTH- 
CEN which has spanned a quarter of a 
century. In 1964, the Navy's Bureau of 
Weapons identified the need for an 
occupational health program which 
would encompass al! fleet readiness 
and training ordnance field activities. 
The Bureau's idea for a comprehen- 
sive occupational health program 
began to take shape with the broaden- 
ing of the occupational health function 
of the Naval Ammunition Depot, 
Crane, IN. In 1967, the Crane program 
was formalized with the establishment 
of the Naval Ordnance Systems Com- 
mand Environmental Health Center. 
On 1 July 1970, the Environmental 
Health Center became a Headquarters 
Detachment of the Naval Ordnance 
Systems Command (N A VORD), Cin- 
cinnati, OH. In October 1970, it 
became the Naval Ordnance Environ- 
mental Health Center (NOEHC), 
NAVORD. In 1971, NOEHC— re- 
named the Navy Industrial Environ- 
mental Health Center — was brought 
under the aegis of the Bureau of Medi- 
cine and Surgery (BUM ED). In July 
1974, the Center became NAV- 
ENVIRHLTHCEN— an Echelon 3 



shore activity under the command and 
support of BUM ED. In response to an 
increase in requests for fleet support 
and an expansion of its occupational 
health mission, a move by the Center 
to Norfolk, VA, was initiated in 1978 
and completed in 1979. Finally, in 
May 1989, after 10 years on the Nor- 
folk Naval Station in three separate, 
temporary facilities, NAVENVIR- 
HLTHCEN moved into ample, mod- 
ern spaces specifically designed and 
built for the command. 

Since its relocation from Cincinnati 
to Norfolk in 1979 to be closer to the 
fleet, NAVENVIRHLTHCEN's mis- 
sion, staff, and needs have increased 
dramatically, making it necessary to 
find a more suitable base of operation. 

The Center is currently charged with 
coordinating and providing central- 
ized support and services to Navy 
medical activities ashore and afloat in 
the areas of occupational health, 
environmental health, and preventive 
medicine. It is also charged with coor- 
dinating and reviewing all occupa- 
tional health and preventive medicine 
programs under the direction and 
management of BUMED. Finally, 
NAVENVIRHLTHCEN is responsi- 
ble for six Echelon 4 commands: Navy 
Environmental and Preventive Medi- 
cine Units No. 2, Norfolk, VA; No, 5, 
San Diego, CA; No. 6, Pearl Harbor, 
HI; and No. 7, Naples, Italy; and Navy 
Disease Vector Ecology and Control 
Centers in Alameda, CA, and Jack- 
sonville, FL. 

When the Center leased and occu- 



pied 28,000 square feet of new com- 
mand spaces in May 1989, it 
consolidated all its departments and 
staff (except its Echelon 4 commands) 
in one location — a move intended to 
foster much improved communica- 
tions and efficiency among its large 
group of professional and support per- 
sonnel whose work spans the globe. 

NAVENVIRHLTHCEN has dedi- 
cated its new facility to George Marion 
Lawton, M.D., a pioneer in Navy 
occupational health and the Center's 
Officer in Charge from July 1971 to 
July 1974. Dr. Lawton provided the 
organizational foundation for today's 
NAVENVIRHLTHCEN and nurtur- 
ance for its early development. His 
first experience with the Center was 25 
years ago at its inception as part of the 
Medical Department, Naval Ammuni- 
tion Depot, Crane. Subsequently, as 
its Officer in Charge and as the Bureau 
of Medicine and Surgery's Director, 
Occupational Environmental Health 
Division and Deputy Director, Occu- 
pational and Preventive Medicine 
Division, Dr. Lawton's influence and 
guidance were directly felt by the com- 
mand through 1978, and his spirit has 
remained constant there since. 

At the ceremony. CAPT James J. 
Edwards, MC, commanding officer, 
presented Dr. Lawton with a dedica- 
tion plaque in honor of his long- 
standing vision for NAVENVIR- 
HLTHCEN — a vision which has been 
realized with the dedication of the new 
facility. □ 

-NAVENVIRHLTHCEN, Norfolk, VA. 



November-December 1989 



Features 



Dr. Dinsmore's 

Souvenir 



CAPT Harry H. Dinsmore, MC, USN (Ret.) 



Photo by the Editor 




Dr. Dinsmore today 



One of i he most curious photo- 
graphs in the BUM ED Ar- 
chives is an x-ray from the 
Vietnam War showing a mortar shell 
lodged beside the victim's chest wall. 
The patient, a South Vietnamese sol- 
dier, had been riding in an armored 
personnel carrier near Da Nang in the 
late afternoon of 1 Oct 1966 when he 
spotted a Viet Cong mortar squad. It 
was already too late. A Soviet bloc- 
made 60 mm round struck the open 
hatch, deflected off his steel helmet, 
penetrated soft tissue between collar- 
bone and shoulder, then plunged be- 
neath his skin before coming to rest 
below the left armpit. Within minutes, 
his comrades rushed him, still con- 
scious but terrified, to the nearby U.S. 
Naval Support Activity Hospital. 
CAPT Harry H. Dinsmore, MC 
(Ret.), describes what happened next. 



I was eating my evening meal in the 
officers' mess hall at about 5:30 p.m. 
on the evening of 1 Oct 1966. The mess 
hall was located a few hundred yards 



away from the Mass Casualty Center 
(MCC), where many of our casualties 
arrived by helicopter. I was just finish- 
ing when the officer-of-t he-day walked 
in with an X-ray in his hand. I vividly 
recall thinking my colleagues were 
playing a trick on me as we sometimes 
did to each other to break the bore- 
dom. I was assured it was no trick, and 
the patient was at that moment in the 
MCC. I and several other physicians 
hurried down there to take a look. 

An ARVN (Army of the Republic of 
Vietnam) soldier, Nguyen Van Loung, 
age 22, was conscious and had no 
wounds other than the entrance 
wound in the anterior aspect of his left 
shoulder and the obvious 60 mm mor- 
tar round beneath the skin of his left 
anterior chest wall. His heavy denim 
army shirt was pulled into the wound 
and, as later turned out, was badly 
entangled in the mortar round's tail 
fins. Most of the shirt had been cut 
away by the time he arrived. It was 
immediately obvious what had to be 
done. 

I was chief of surgery and the senior 



NAVY MEDICINE 




surgical officer present, However, I 
did not have the first surgical call. Al- 
though there were three to four other 
general surgeons on my staff, with the 
gravity of this situation, I felt that 1 
could not ask or order anyone else to 
do the surgery. 

We called the Navy Ordnance 
Depot and told them our problem. 
They agreed to send a demolition 
expert to the hospital. He arrived 
about 20 minutes later. When shown 
the patient, Engineman First Class 
John Lyons just shook his head in dis- 
belief. The round, he stated, contained 
between 1 and 2 pounds of TNT. After 
measuring the firing pin on the X-ray, 
he pointed out that it was already par- 
tially depressed. The round could go 



Top: Loung with 60 mm mortar round 
embedded in left chest wall awaits 
surgery the evening of 1 Oct 1966. Right: 
Patient, ordnance expert John Lyons, 
and Dr. Dinsmore pose for the press fol- 
lowing the newsmaking surgery. 




November-December 1989 




Above: Loung awaits skin-grafting 
procedure 7 days following the removal 
of the mortar round. Right: Dr. Dinsmore 
completes the graft. 



off at any time even without being 
handled! 

In the meantime, several corpsmen 
and others were starting to position 
sandbags around the operating table 
in the OR at one end ofaQuonset hut. 
However, their activity was stopped 
for two reasons. One, the round was of 
such a size that it could not be held in 
place with an instrument during 
surgery, but had to be hand-held. 
There was no way this could be done 
from behind sandbags. The second 
reason was the more determining one. 
Lyons told us that sandbags would do 
no good. If the round went off, the 
whole Quonset hut would be gone! 

The patient was taken to the operat- 
ing room by stretcher, and I never saw 
such careful, tiptoeing stretcher car- 







/ 







riers. They placed him on the operat- 
ing table, stretcher and all. He was 
sedated, given a general anesthetic by 
our anesthesiologist. LT Jerry 
Warren, intubated, and then attached 
to the Bird machine, an automatic res- 



pirator. Warren then left. I had 
decided that no one should be there 
who didn't have to be. Several corps- 
men — OR techs — volunteered to 
assist me and, while 1 was in the locker 
room changing clothes, one of the 



a 



NAVY MEDICINE 




Loung flanked by his surgeon, Dr. Dins- 
more (right), and LT Dick Virgilio 1 
month postop. Below: On 19 Feb 1967, 
CAPT Dinsmore received the Navy 
Cross and congratulations from GEN 
William Westmoreland. 




other surgeons offered to do the 
surgery. He could see how scared I 

was. The OR techs set up the Mayo 
trays and then left, I decided that only 
Lyons and I would stay. Lyons would 
lake the round and disarm it after re- 
moval. 

I chose not to do a skin prep; Lyons 
urged that there be no movement of 
the round within the tissue, no twisting 
or lateral motion. He felt the round 



should not be moved at all until it was 
lifted straight from the chest wall. To 
accomplish that end, I planned to 
make an elliptical incision completely 
around and away from the mortar 
shell. I proceeded with the surgery. 

When the round had been com- 
pletely encircled, I lifted it with the 
overlying soft tissues directly away 
from the chest wall, thinking every 
second that my world was going to 
end, as the shell was just a foot from 
my face. 

Just then, a major problem became 
evident. As the shell came away from 
the chest wall, I felt something re- 
straining it. The patient's blood- 
soaked shirt, which was also firmly 
trapped within the entrance wound, 
was badly entangled in the mortar 
round's tail fins. With a Mayo scissors, 
the heaviest we had, 1 spent an addi- 
tional, harrowing 10 minutes cutting 
through multiple folds of heavy, wet 
cloth to get it free. I handed the shell, 
with the surrounding tissues, to Lyons 
and then hurried over to open the door 
for him. He took the round to a nearby 
sand dune, where he defused it and 
emptied the TNT. He later returned it 
to me as a keepsake. 



This entire procedure had taken 
about a half hour. The OR techs then 
returned. After regloving, 1 completed 
the procedure by obtaining hemosta- 
sis, removing the remaining cloth frag- 
ments, and further dcbriding the 
wound, all accompanied by copious 
irrigation. This took about an addi- 
tional 30 minutes, but that part of it 1 
barely remember. We applied sterile 
dressings; skin grafting was planned 
for later. 

The patient's postoperative course 
was uneventful, and he was very grate- 
ful. The wounds were closed with split- 
thick ness grafts about a week later, 
which took well and healing pro- 
gressed satisfactorily. There was some 
resultant weakness of the left shoulder 
because of the loss of a portion of 
greater pectoral muscle, but the func- 
tional result was good. The patient 
returned to full-duty status within 2 
months. 

For his heroic performance, CAPT 
Dinsmore was awarded the Navy 
Cross. D 



Dr. Dinsmore practices surgery in Punxsu- 
tawney. PA. 



November-December 1989 



9 



Total Quality Management: 

Mandate For Change 



CDR William J. Lambert, Jr., MSC, USN 
LT Richard P. Beaudoin, MSC, USN 



" We will commit to excellence, to a relentless pursuit of 
continuous improvement, and to removing barriers to 
increased performance, productivity, and timeliness in all 
that we do." — SECNAV, CNO, and CMC(7) 



What is the nature of this commitment our Navy 
Department leadership has laid down for us? 
What is driving it? How is it expected to occur? 
The short answer is that the "commitment" is to implement 
something called total quality management (TQM). It is 
being driven by a presidential mandate to establish a "pro- 
ductivity improvement program for the federal govern- 
ment ... to improve the quality, timeliness, and efficiency 
of [government] services by . . . 1991. "(2) 

The Department of the Navy (DON) expects TQM to 
become part of our management philosophy and processes 
through education, training, day-to-day operations, and 
leadership. According to DON, this "requires commitment 
and involvement of managers at all levels.'YJ) 

This article reviews the Department of Defense (DOD) 
mandate for a TQM program, discusses key features of the 
TQM concept, and highlights the involvement of Navy 
medicine. 

TQM officially began with the DOD community when a 
Departmental "Posture on Quality" was issued 30 March 
1988.(4) In August 1988, a TQM Master Plan was pub- 
lished, outlining how the Department intended to imple- 



ment it's part of the federal program. The "DOD strategy" 
for TQM "aims at achieving . . . continuous improvement 
of products and services . . . [across] the breadth of DOD 
activities." "Products and services" include "everything 
that DOD does, every action that is taken, every system 
that exists, [and] involves processes and products that can 
be improved or services that may be performed more 
efficiently."(J) 

Although acquisition and engineering functions re- 
ceived much of the initial attention in the program, human 
resources and support services (including health care) are 
now being brought into focus as well. "The DON is imple- 
menting TQM as the top priority initiative to achieve 
performance improvement on a continuing basis. "(6) A 
DON TQM implementation plan was published 4 Nov 
1988. According to this plan, medical and dental care 
activities are to implement TQM by 1990.(7) 

What is TQM? 

As a concept, TQM has been around for more than 40 
years, thanks to the pioneering efforts of W. Edward Dem- 
ing,(<¥) J.H. Juran,(9) and others. The management proc- 
esses employed by these individuals have been credited 
with the industrial miracle achieved by Japan in recent 
years. A number of major American manufacturing firms 
have applied the concept with impressive results. Only 
within the past few years, however, have the service indus- 
tries begun to apply TQM principles in a formal way. The 



10 



NAVY MEDICINE 



health care industry is just beginning to get on the band- 
wagon, frequently under the banner of "productivity 
improvement,"(/0) The key features, or principles, of 
TQM may be summarized as follows: 

• Strategy Development and Execution. This involves 

looking at the environment or situation relative to a partic- 
ular mission, assessing the alternatives acceptable for 
meeting the mission, deriving the most effective and effi- 
cient pathways, putting together a plan of action for pro- 
ceeding, and monitoring progress. This process should 
look familiar to those who have worked with strategic 
planning. If done successfully, it should yield a refined 
mission, organizational goals and objectives, and a long- 
range vision about where the organization should be in a 
number of years from now. Organizations that lack coher- 
ent, articulated, long-range vision and congruent goals 
tend not to be able to focus on product improvement or 
quality concerns. Strategy development is, therefore, an 
essential first step in TQM implementation. 

• A Commitment to Quality. The admonition associated 
with this principle of TQM is "do it right the first time." In 
the health care arena the need for identifiable and measur- 
able outcomes is not an alien concept. A lot of attention is 
accorded to "quality control," or "quality assurance," but it 
is generally applied in a piecemeal fashion. In TQM, the 
commitment to quality must be all encompassing. Indica- 
tors of quality need to be established for each service or 
facet of service provided. Evaluations and improvement 
goals need to be measured against these indicators. Man- 
agement needs to ensure that this aspect is a part of the 
strategy-making and the goals and objectives development 
process. The "crew" must accept the commitment to qual- 
ity as their primary organizational purpose. Finally, there 
must be a process for continuous improvement. Problems, 
or deviations from the ideal, need to be recognizable 
through quality control processes, and methods for correc- 
tion or improvement locked in place. The latter process is 
facilitated by a climate which encourages innovation. 

• Process Orientation. Process involves the way we get 
things done. It includes both the tools used and the way 
they are applied. Incoming materials or supplies must meet 
specifications, production outcomes must be within the 
quality control range, and the product or service must 
measure up to performance standards. Finally, the pro- 
duct must meet the customer's expectations. All phases of 
a process must be clearly identified and systemically con- 
trolled through measurable standards. 

• An Emphasis on Outcome Measurement. This is a dis- 
tinctive feature of TQM and separates it from many other 
forms of management techniques. It involves the use of 
statistical tools to plan, measure, and evaluate system and 
product quality. The use of microcomputers to assist in 
applying statistics, tracking quality indicators, and aiding 
in systems and decision analysis is almost essential. On the 
other hand, much of the planning necessary to institute 



TQM does not require computer or statistical applica- 
tions. A rule of thumb is that the planning and develop- 
ment associated with TQM relies heavily upon qualitative 
techniques, while product or service output evaluation 
places emphasis on quantitative analysis. 

• Orientation to Human Resources. A sound employee 
relations and benefits package, which is perceived to be 
equitable and competitive, is an important component of 
any human resources program. Such a package empha- 
sizes that people are the key to quality output. However, 
TQM also cashes in on the desire of people to make a 
worthwhile contribution to a good product, and the need 
to feel they are a part of an organization which is known 
for the quality of its products. Involvement of people at the 
lowest possible level of production is considered essential. 
Quality circles, recognition and awards programs, bottom- 
up planning, and innovation-sensitive programs are some 
of the recommended ways of getting people involved. 
Appropriate delegation and support for individual initia- 
tive are vital, 

• Customer Orientation. According to TQM philosophy, 
the customer is the reason for existence. He/she is con- 
sidered to be the best judge of the ultimate value of the 
services provided. There are two levels of customer orien- 
tation—internal and external. The internal customer uses 
the services of the rest of the organization. In the health 
care facility these include people working in areas such as 
benefits, public relations, recreation, education programs, 
housekeeping, supply, food service, and ancillary clinical 
services (laboratory, staff clinic). Someone is always the 
customer of someone else and needs to be treated as such. 
The external customer is the individual or organization 
outside of the facility that uses the services produced. In 
Navy medicine external customers include not only actual 
patients, but all authorized beneficiaries, the "line com- 
munity," and collegiate organizations such as other federal 
and civilian health care services. In other words, ail of the 
people who are in a position to use our product and judge 
its quality by their perceptions and their standards. 

Navy Medicine and TQM 

The Navy medical community formally began the task 
of implementing TQM in the spring of 1989 when the 
Commander, Naval Medical Command appointed CAPT 
Robert K. Zentmyer, MSC, to coordinate the program 
and sent a message on TQM to our top leadership in the 
field. (1 1 ) This initiative began a process that has yielded a 
set of "guiding principles" to serve as "the base upon which 
we can build a strategic plan for the Navy Medical Depart- 
ment and . . . [to] serve as a common set of values towards 
the continuous improvement goal of Total Quality Man- 
agement.'^ 72) The organizational structure for guiding the 
TQM effort is thus linked to the areas of innovation and 
strategic planning at the Bureau of Medicine and Surgery 
level (BUM ED OOZ). This approach fits well into the TQM 
framework and is necessary for its success. 



November-December 1989 



11 



Concluding Observations 

TQM is both a management philosophy and a process 
for achievi ng quality. It incorporates a number of manage- 
ment concepts that have been developed and tested over 
the years, such as industrial management engineering, 
motivation theory, and management by objectives. 

TQM must be an ongoing, total corporate project, with 
goals and objectives formulated for both the organization 
and the services provided. This needs to be done with the 
collaboration of those responsible for the product or ser- 
vice. 

TQM has worked well in manufacturing industries and 
in procurement processes. Health care organizations pre- 
sent a special challenge, however, because of their unique 
corporate cultures and other organizational complexities. 
The special environments of government and military cul- 
tures compound the situation, so that implementing TQM 
can task the imagination and leadership abilities of the best 
change managers. At the same time, this situation presents 
a special opportunity to initiate the new TQM philosophy, 
which "will require fundamental changes in the way we 
manage and in the way we perform our daily tasks, "(IS) 
This is a key point and needs to be understood if TQM is to 
succeed. The TQM approach to management involves not 
only changes in attitudes and style, but also requires under- 
standing and patience. Although some benefits of TQM 
may become apparent within months, most organizations 
do not realize fundamental improvements until 3-5 years 
have passed. 

TQM is not something that can be put on automatic 
piioi. Successful implementation and long-term integra- 
tion of a TQM program requires that leadership, supervi- 
sory, and staff personnel at all levels and activities 
continuously work to become acquainted with the bene- 
fits, principles, and processes of the concept. An organiza- 
tion and leadership structure must be established that 
ensures continued optimal coordination and integration of 
TQM with innovation, strategic planning, and organiza- 
tional change efforts. This "strategic management" 
approach will establish a focus for continuous improve- 
ment as well as survival of the process within Navy 
medicine. 

References 

1. Webb JH Jr. Trosi CAH. Gray AM: Productivity Improvement 

Guiding Principles. Department of the Navy, 1987. 

2. Reagan R: Productivity improvement program for the Federal 
Government (Executive Order 12637 of April 27. 19881. Note: This 
supersedes E.O. 12552. Feb 25, 1986. which initiated the federal produc- 
ts itv improvement TQM effort. Federal Register. April 29. 1988. pp 
15349-15351. 

3. HoflmannGC: Total Quality Management. Department of Navy 
Memorandum. Specification Control Advocate General of the Navy, 
Dec 20. 1988. 

4. Carlucci FC: Department of Defense Posture on Quality. 1>0D 
Memorandum, Secretary of Defense. March 30, [988. 

5. Total Quality Management Master Plan, Department of Defense, 
Aug 1988, 



6. Garrett LH 111: Total Quality Management (TQM). Department 
of Navy Memorandum, Under Secretary of the Navy, Nov 8, 1988. 

7. Garrett LH [II: Department of the Navy Total Quality Manage- 
ment Implementation Plan. Department of Navy Memorandum. Under 
Secretary of the Navy. Nov 4. 1988. 

8. Dealing WE: Out of Crisis. Cambridge. MA, Institute of Technol- 
ogy. Center for Advanced Engineering. 1986. Also. Walton M: The 
Denting Management Method. New York, The Putnam Publishing 
Group, 1986. 

9. Juran JM: Managerial Breakthrough: A New Concept of the 
Manager's Job. New York, McGraw-Hill Book Co, 1964. Also, Juran 
JM: Juran on Planning for Quality. New York, The Free Press, 1988. 

10. Berwick DM: Continuous improvement as an ideal in health care. 
N Engl J Med 320:53-56, Jan 5. 1989. 

It. Commander. Naval Medical Command: Guiding Principles for 
Navy Medical Department. Message: R U3I400Z, May 1989. 

12. Zimble JA: Total Quality Management. Bureau of Medicine and 
Surgery Memorandum (5250: SenOOZ Oil), Surgeon General of the 
Navy, Aug 22, 1989, 

13. Hoffmann, op. cit. □ 

CDR Lambert isan assistant prolcssor, Army-Baylor University Grad- 
uate Program in Health Care Administration, Academy of Health Sci- 
ences, Fort Sam Houston, TX. I I Bcaudoin is a graduate student in the 
Army-Baylor HCA Program. He is currently doing his residency at the 
Bureau of Medicine and Surgery, Washington. DC. 



NAVY MEDICINE 



Bimonthly 



Navy Medici 

21QQ E S 



ITKSuTS 



29 Sept 1989 



$6.50 Domestic 
$8.15 Foreign 



,r CirM a, PjOU,, dJWM. &> ,**«■*. lead M HP- * CtJtl .Vi ivufr 

lcine. Department of the Wavy, Bureau of Medicine 1 Surgery (00D4) 
t. ( N.W., Washington, DC 20372-5120 



■ UMl Aukna at m ^•M*,IBi,l Cnrrri 3jvi< GD -,i ,f ,■ ,i_,- ,„- W*l |^v 

Department of the Navy, Bureau of Hsdlclne 1 Surgery -10004) 
N.W.. Washington, PC 20372-5130 



2300 E St. 



i ".'. , ^ ,3„- .-, ■■■■ ,;f«reis-inhl« U(ir IQFM, 



Qepturtawot of the Navy, Bureau of Medicine a Surgery I0OD4! 
2300 E St., a.w., Washington, DC 20373-5120 



Jen K. Herman, Navy Medicine, Department of the Navy, Bureau of Medicine a 
Surgery IO0D4I , 2300 s St., S.V., Wellington, DC 20372-5120 



Virginia M. Novinski, Navy Medicine, Department of the Navy, Bureau of Modi 
cine a. Surgery [Q0D4), 2300 E St., M.W,, Washington, DC 20372-5120 



.::.-. - f t:_\- :;jvV 



Compl... M»IIb,b *ani.< 



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.2 



NAVY MEDICINE 



A Prospective Role 
in Navy Medicine 



Medical 
Anthropology 



Bruce H. Grant 



Anthropology has come of age. No longer is it 
relegated to bespectacled professors examining 
fossils in dusty museums or studying primitive 
tribes in faraway places. These stereotypical notions have 
given way to a new breed of anthropologists — applying 
theories and expertise to solving practical problems. No- 
where is this more evident than in the emerging field of 
medical anthropology. It stands uniquely at the crossroads 
of medicine and culture and offers new and creative 
insights into some of the pressing concerns of health and 
disease. 

As a subdiscipline of anthropology — the science of man 
in all his biocultural dynamics — medical anthropology is 
concerned with the interrelation of behavioral and bio- 
medical factors that impinge on health and health care. It 
emphasizes the notion that health and disease are as much 
a social and cultural phenomenon as a biological phenom- 
enon. Two salient features characterize its scope: beliefs 
and patterns of human behavior. The former involves the 
ethos, values, and systems of meaning among different 
cultures; the latter includes kinship and social structure, 
economic and political organization, and forms of social 
interaction. Both are integral to the functioning of any 
society or culture and influence the ways in which sickness 
and health are perceived and managed. These perceptions 
and practices vary enormously and must be carefully con- 



sidered to ensure the success of any health care program. 
The strongest asset of medical anthropology is its holis- 
tic approach to health and disease. Environmental, epide- 
miological, clinical, and sociocultural data are all grist to 
the medical anthropologist. Each of the data is interpreted 
in an overall context of the environment, the individual, 
culture, and disease to achieve greater understanding of 
specific health-related problems. It is the elicitation of the 
complex "causal network" of disease etiology and trans- 
mission, rather than specific behavioral or categorical 
determinants of disease (the domain of epidemiology), 
which holds the greatest promise for medical anthropol- 
ogy.(/) 

Anthropological 
Research Methods 

Unlike the more quantitative research methods of epide- 
miology, anthropological research methods are primarily 
qualitative. Rather than administer survey questionnaires 
to large samples of a target population, anthropologists 
resort to "ethnographic" or culturally descriptive methods 
such as participant-observation, in-depth interviews, life 
histories, and the use of key informants. Unfortunately, 
clinicians and biomedical researchers are often uncomfort- 
able with these methods. Unless data is quantified and 
statistically analyzed, they often feel it is insignificant. 



November-December 1989 



13 



"nonscientific," or too abstract for meaningful application. 
Nothing could be further from the truth. 

Qualitative methods, using smaller numbers of people, 
focused on a specific problem, and less rigidly designed 
often afford great validity and utility. (2) The descriptive 
data yielded by qualitative research methods provides a 
behavioral context in which to interpret quantitative data. 
Not only does the anthropological approach "ground" 
statistical data in cultural reality, (J) it may also help in the 
identification of potential health problems. 

Disease Control 

One important area for the application of anthropology 
is disease control. The transmission of disease is often 
influenced by many sociocultural factors such as kinship 
structure, sleeping arrangements, house design, water and 
waste management, dietary customs, migration and settle- 
ment patterns, child-rearing methods, agricultural tech- 
niques, religious practices, and beliefs about the etiology of 
diseases (such as witchcraft, sorcery, and possession). 
These factors are often best explained by anthropological 
research. 

Malaria, for instance, has been of long interest to medi- 
cal anthropology. International eradication efforts have, 
for the most part, failed. While it is becoming apparent 
that malaria may never be eradicated, control of the dis- 
ease will also likely prove elusive if only reductionist, 
technological measures are used. To address this dilemma, 
attention is being increasingly directed at the sociocultural 
variables that affect and influence control efforts.(^) The 
technological focus of antimalarial campaigns (i.e., resid- 
ual insecticide application, ecology control, chemother- 
apy, etc.) frequently precludes community involvement 
and participation, elements that require an analysis of the 
social structures and cultural norms of indigenous popula- 
tions. More integrated and holistic approaches to malaria 
control planning may help ensure the social soundness, 
local receptivity, and overall effectiveness of program 
efforts. 

The Navy Context 

How, precisely, can medical anthropology be of use in 
Navy medicine? Due to its sociocultural emphasis on dis- 
ease causation, qualitative research methods providing 
descriptive information, and a holistic orientation to 
health problems, medical anthropology can directly con- 
tribute to the mission of the Navy Medical Department in 
many ways. Programs dealing with sexually transmitted 
diseases, tuberculosis, malaria, or other diseases of mil- 
itary importance can be improved by the medical anthro- 
pologist. Environmental modification efforts (e.g., water, 
wastewater, and solid waste management), food service 
sanitation, and vector control programs can also be 
improved by anthropological expertise. Education efforts 
directed at Navy personnel, their dependents, and the local 
community — dealing with issues from substance abuse to 



stress reduction — can also benefit from anthropological 
insights. 

In assessing the role that medical anthropologists can 
perform in the Navy, it is important to realize that Navy 
personnel do not operate in a vacuum. Ashore or afloat, 
the health and welfare of the naval forces is to a large 
extent determined by the local communities and indige- 
nous peoples with whom they interact; therefore, this must 
always be considered in any prevention program. 

At shore stations in the United States or overseas, inter- 
action with "locals" may adversely affect the health of 
Navy personnel; poor housing, unhealthy or improperly 
prepared foods, unsanitary conditions, contaminated 
water, and intimate contact with diseased individuals may 
exact their toll. Aboard ship, contact with "locals" — once 
liberty is called — may jeopardize the crew's health and 
impair the ship's operational effectiveness. This is espe- 
cially true if ports are visited or areas are transited where 
infectious diseases are endemic and/ or epidemic. 

Ethnic diversity and differing lifestyles of personnel 
within the Navy must also be considered. Increasing 
numbers of Navy personnel are Hispanic or Asian, and 
other minorities, including blacks and women, are entering 
the Navy in greater proportions. These groups invariably 
have unique health care needs related to their sociocultural 
backgrounds. 

Navy personnel cannot be seen in isolation from their 
particular sociocultural or ecological milieu. The need for 
gathering and analyzing data that is cognizant of this 
interaction, as well as recognizing the health care needs of 
minority groups in the Navy, is of central importance for 
the continued success of the Navy's preventive medicine 
agenda. 

The medical anthropologist is ideally qualified to assist 
in the design, implementation, and maintenance of preven- 
tive medicine or other health care programs. This includes: 

• Identifying groups at high risk for specific diseases. 

• Assessing the scope of particular health-related prob- 
lems. 

• Focusing the goals and objectives of prevention pro- 
grams. 

• Culturally sensitizing measurement instruments used in 
epidemiological surveillance. 

• Coordinating program efforts. 

• Evaluating program effectiveness. 

The Medical Service Corps 

Medical anthropologists, commissioned as officers in 
the Medical Service Corps, can join forces with the epide- 
miologist, entomologist, parasitologist, and environmen- 
tal health officer as well as the physician, nurse, and 
corpsman. Appropriate duty stations include: 

• Navy Environmental and Preventive Medicine Units 
(NEPMU). 

• Naval Medical Research Units (NAMRU). 



14 



NAVY MEDICINE 



• Disease Vector and Ecology Control Centers (DVECC). 

• The Preventive Medicine Service of naval hospitals. 

Within these organizational units, medical anthropolo- 
gists can become an integral part of the Navy Medical 
Department. The following are examples of specific tasks 
which may be delegated to a medical anthropologist: 

• Assess the behavioral aspects of selected infectious and 
parasitic diseases. 

• Provide consultation to medical personnel treating cul- 
turally diverse patients. 

• Gather and analyze biosocial data pertaining to sub- 
stance abuse among Navy personnel. 

• Explore ways to improve chemoprophylaxis com- 
pliance and "malaria discipline" among Navy personnel in 
malaria endemic areas. 

• Conduct Health Risk Appraisals for the Physical Fit- 
ness Program and determine appropriate methods for par- 
ticipants to modify behavior. 

• Function as a medical intermediary between overseas 
stations and indigenous populations. 

This list is by no means exhaustive. The potential duties 
and responsibilities of medical anthropologists in the Navy 
Medical Department are extensive and wide-ranging. 



Conclusion 

Navy medicine has a long tradition of excellence. For 
more than 100 years, it has been a leader in preventive 
medicine and applied biomedical research. To maintain 
this tradition and fulfill its mission, the Navy Medical 
Department must continue to explore the potential for the 
application of new and innovative biosocial and medical 
knowledge. The incorporation of medical anthropologists 
into the Navy Medical Department is timely and appro- 
priate. It promises to be a creative union directly benefiting 
the health and operational readiness of the naval forces. 

References 

1. Dunn FL, Janes CR: Introduction: Medical anthropology and 
epidemiology, in Janes CR, et al (eds): Anthropology and Epidemiology. 
Dordrecht, Netherlands, D Reidel, 1986, pp 3-34. 

2. Buzzard S: Appropriate research in primary health care: An 
anthropologist's view. Soc Sci Med 19(3):273-277, 1984. 

3. Nations MK: Epidemiological research on infectious disease: 
Quantitative rigor or rigormortis? Insights From Ethnomedicine, in 
Janes CR, et al (eds): Anthropology and Epidemiology. Dordrecht, 
Netherlands, D Reidel, 1986, pp 97-123. 

4. Auit S: Anthropological aspects of malaria control planning in Sri 
Lanka. Med Anthropol 7(2):27-50, 1983. D 



The author is with the Department of Anthropology, Catholic Univer- 
sity of America, Washington, DC 20017. 



Navy Nurse's Ambulatory 
Care Symposium 

The 2nd Annual Navy Nurse Corps Ambulatory Care Symposium 
and dinner will meet 13-14 March 1990 at the Bally Hotel in Reno, 
NV. 

The dinner on the 13th and the 1-day symposium the following 
day will be held in conjunction with the 15th Annual National 
Conference of the American Academy of Ambulatory Nursing 
Administration (AAANA). The symposium is open to all active 
duty, selected reserve, and retired Nurse Corps officers practicing in 
ambulatory care. 

The symposium provides a forum for ambulatory nurses to net- 
work and exchange ideas and acquire new insights for solving com- 
mon health care problems. Samples of AAANA Nursing 
Administration and Practice Standards which have been imple- 
mented with naval medical treatment facilities (MTFs) will also be 
available for sharing. 

For more information and registration forms contact: CDR Jane 
W. Swanson, Washington Navy Yard Branch Medical Clinic, 
Washington, DC 20374-1832. Telephone: Autovon 288-3492, Com- 
mercial (202)433-3493/94. 



November-December 19S9 



15 

















\~ 



Stretcher team preparing for trolley/litter transport. 



16 



NAVY MEDICINE 



Transportation 

of 
Litter Patients 



in 
USS Missouri 



CDR Jack W, Smith, MC, USN 
LT Murray C. Norcross, MC. USN 
LT S. William Elwood. MC, USN 



The reactivation of the Iowa 
class battleships has captured 
the imaginations of a new gen- 
eration of sailors who have the oppor- 
tunity to serve in these modernized 
dreadnaughts. Graceful, mighty, and 
awe-inspiring, their decks echo the 
events of American naval history from 
World War II to the present. The lure 
of. serving on USS Missouri (BB-63), 
the ship upon which the surrender end- 
ing World War II was signed in 1945, 
has been irresistible for many Navy 
men, and physicians are not immune. 
Missouri, like the other ships in the 
class, was built in the early 1940's and 
designed to fight and survive in battle 
with the most powerful Japanese bat- 
tleships of that era. In order to allow 



these ships to survive and fight after 
direct hits by the huge shells of the 
world's largest naval guns, their design 
included heavy armor as thick as 17 
inches in places and a redundancy of 
ship systems rare in most warships 
today. Now, with their 5- and 16-inch 
gun systems augmented by the addi- 
tion of Harpoon and Tomahawk mis- 
siles, these rugged and reliable 
behemoths have returned to service to 
respond to the threat of antiship cruise 
missiles and to reinforce our carrier 
battle groups in the projection of sea 
power. 

However, the very features which 
make these battleships such excellent 
and survivable weapons platforms in 
armed conflict (i.e., heavy armor and 



extensive compartmentalization) 
create special problems for the move- 
ment of the sick and injured within the 
ship. Unlike more modern large ships 
having equipment elevators that may 
be used to transport patients between 
decks (LHA's have a dedicated medi- 
cal elevator), litter patients on Mis- 
souri must still be hauled up and down 
ladders using ropes, stretchers, and 
muscle. 

Missouri's sick bay is located on the 
third deck between turrets I and 2 (see 
illustration) and can only be reached 
by descending two nearly vertical 
ladders into the "armored box." Sick 
bay contains a 20-bed ward, an operat- 
ing room, a laboratory, and an X-ray 
facility. 



November-December 1989 



17 



The location of Missouri's monorail is 
on the third deck. It begins at sick bay 
and continues down the full length of 
"Broadway" (engineering mainspace) 
ending at turret #3. (Illustration by HM2 
Eduardo Jimenez, Jr.) 



^ , TUrret #3 

Flight Deck | 




Turret #2 

Tbrrel 



■^uuty 




360' 

■^Length of Monorail|- 



Sick Bay 



Once the third deck is reached, 
depending upon where he entered the 
ship, the patient must usually still tra- 
verse numerous obstacles including 
winding, narrow passageways and 
many of the infamous "knee knockers" 
— fittings for watertight hatches only 
27 inches wide and so called for the 
placement of their lower edge between 
8 and 24 inches from the deck. The 
movement of injured and ill personnel 




through this veritable obstacle course 
is a challenging, backbreaking, and 
time-consuming chore requiring four 
trained stretcher bearers for each litter 
case. 

During general quarters evolutions 
(the highest level of shipboard combat 
readiness), injured or ill personnel are 
triaged and stabilized at the nearest 
battle dressing station (BDS) until 
movement to main sick bay can be 

Trolleys with attached ropes and hooks 




accomplished. On Missouri, besides 
main sick bay, BDSs are located on 
the main deck forward in the ward- 
room (officer dining room), on the 
second deck aft on the crew's mess 
deck, and on the third deck on "Broad- 
way" to serve the engine rooms. 

In the event of a mass casualty situa- 
tion, injured personnel are moved in 
order of triage category to main sick 
bay as soon as operationally feasible. 
Should numbers of casualties in excess 
ward capacity be sustained, berthing 
areas attended by medical personnel 
would be utilized as temporary medi- 
cal wards for the less seriously injured. 
In addition to the movement of 
patients within the ship, casualties 
from other ships may be received when 
the ship operates as the centerpiece of 
a battleship battle group (BBG). In 
this situation, patients would be 
received mostly by helicopter medevac 
from smaller or less medically capable 
ships. 

Missouri's, flight deck is located on 
the fantail. Depending upon the 



18 



NAVY MEDICINE 



number of patients and the nature of 
their injuries they may be triaged and 
stabilized at the aft BDS or in some 
circumstances, weather permitting, 
might be carried forward on the 
weather decks before entering the ship 
to avoid the maze of hatches and pas- 
sageways within. However, this option 
would not be available in heavy 
weather or in certain operational 
environments. 

During "Earnest Will" operations in 
the North Arabian Sea late in 1987, the 




transportation of litter patients by 
trained stretcher bearer teams from 
the aft BDS to main sick bay using 
Stokes litters required an average of 
25-30 minutes. Although further train- 
ing and practice might result in some 
small time savings, this was considered 
to be an excessive delay for any but 
most stable patients since provision of 
medical care enroute is virtually 
impossible. We therefore sought a 
means of improving upon the move- 
ment of casualties within the ship. 

Our solution to this problem is sim- 
ple. It uses existing equipment and 
structures within the ship, utilizes only 
a few items of special equipment 
within the capability of ship's force to 
fabricate, and cuts the time of trans- 
port by half. 

All Iowa class battleships have a 
monorail running more than 360 feet 
along the third deck from turret 2 (in 
main sick bay) to turret 3 just forward 
of the aft mess deck. This rail was 
designed for the movement of powder, 
projectiles, and equipment between 
the 16-inch gun turrets forward and 
aft. Heavy engineering equipment may 
also be moved between points along 
the rail which has removable sections 
to allow for closure of watertight 




Missouri's "Broadway" in engineering 
spaces, showing monorail. 

hatches during general quarters, but 
which can be set up and fully func- 
tional within a matter of minutes. 

With the assistance and expertise of 
Missouri's engineering department, 
two rolling trolleys were constructed 
(see photograph). To hold the litter, 
hooks with an eyelet for rope or cable 
attachments were cut from W-inch 
steel plates, and then attached to the 
trolley by triple strand nylon rope with 
the assistance of the boatswain's mates 
of the ship's deck force. When con- 
nected to the rail, a litter could now be 
moved along the rail above the "knee 
knockers" with relative ease and speed . 



Initially, only Stokes litters were used 
on the system, but Neil-Robinson and 
Miller-Abbot stretchers have subse- 
quently been used with similar success. 
We have continued to use four 
stretcher bearers with the rail system 
to assure safety in case of equipment 
failure, but the modification of the 
equipment to utilize climber's D-rings 
with safety snaps, two stretcher bear- 
ers should be able to safely transport 
each patient. Since "Broadway," the 
space which the rail traverses is much 
wider than other passageways in the 
ship, it offers additional advantage of 
room for a medical attendant to pro- 



November-December 1989 



19 








Battleship Missouri in action 



vide attention for or closer monitoring 
of the patient along the way. The sav- 
ings in time of transport and effort 
required by the stretcher bearers have 
been significant, and the discomfort of 
the trip for the litter patient has actu- 
ally been reduced for the rail portion 
of the trip. 

A few minor problems have been 
encountered using the rail system. 
Most obvious, the rail cannot be used 
during general quarters or other evolu- 
tions in which full watertight integrity 
is vital. In addition, we found that 
because the rail is seldom used, paint 
chips fall onto the patient necessitating 



the use of safety goggles or a face 
shield. Finally, practice and coordina- 
tion with other departments are 
required to assemble the rail quickly 
and smoothly when needed. The great- 
est benefit so far has been in the trans- 
port of medevac litter patients back 
and forth between the flight deck and 
Missouri's sick bay. 

The rail system for patient move- 
ment within Missouri has been used 
successfully for both exercises and 
actual patients for more than 1 year. 
While it has limited usefulness when 
actually operating at general quarters, 
it is very helpful in the movement of 



patients from the battle dressing sta- 
tion to main sick bay following the 
relaxation of condition Zebra (all 
hatches closed), and has proven very 
effective in expediting the movement 
of medevac cases from sick bay to the 
flight deck and vice versa, flu* time 
saved through its utilization (greater 
than 50 percent reduction in transit 
time from the aft BDS) could prove to 
be the margin between life and death in 
the critically ill or injured patient. □ 

Dr. Smilh is USS Missouri's senior medical 
officer. Drs. Norcross and Elwood also serve 
aboard Missouri, 



20 



NAVY MEDICINE 



Highlights From the Navy Medical 
Research and Development Command 

Bethesda, MD 



• New Prediction Model Relates Helmet 
Weight to Aircrew Neck Injury Risks 

Aircrews of today's high performance tactical aircraft 
face a significant risk of neck injury during the G 
maneuvers, hard landings, or emergency egress, a risk 
which is increased when helmet-mounted sighting sys- 
tems, night vision goggles, and laser-protective hard- 
ware change both the helmet's weight and center of 
gravity. Until recently, empirically-based guidelines 
have not been available to predict the likelihood of neck 
injury under varying conditions of G stress and helmet 
weight. Now, scientists at the Naval Biodynamics 
Laboratory (NBDL) in New Orleans, LA, have com- 
pleted an extensive effort to model the reductions in 
x-axis G tolerance (-Gx) that are associated with 



• Vascular Anastomoses Without Sutures? 

During wartime, large numbers of combat casualties 
can be expected to require the emergency rejoining 
(anastomoses) of large blood vessels. Standard suturing 
of blood vessels can be time consuming and requires 
skilled surgeons and hospital facilities which will not be 
available at forward echelons of combat medical care. 
Funded by a Navy contract, the Johns Hopkins Applied 
Physics Laboratory, Laurel, MD, is developing a sim- 
ple, rapid technique for the sutureless anastomosis of 



• Medical Database Predicts Health Risks 
for Deployed Sailors and Marines 

For more than 20 years the Naval Health Research 
Center (NHRC) in San Diego, CA, has compiled a 
unique set of personnel and medical data files on all 
active duty Navy and Marine Corps personnel, which 
can be used for determining the disease and occupa- 
tional injury rates for any segment of the Navy popula- 
tion worldwide. Recent updates to this computerized 
system have allowed NHRC to analyze effectively the 
disease risk to all deployed sailors by following every 



increases in effective head weight. Experimental data 
curves developed at NBDL predict, for example, that 
wearing a 3.5-pound aircrew helmet increases the head 
weight of the average adult male by 37 percent and 
reduces the -Gx impact tolerance by 26 percent. Night 
vision goggle systems can raise the total head weight to 7 
pounds, reducing the tolerance limits by 42 percent and 
45 percent respectively, for male and female aircrew 
personnel. These data, which are essential for both 
human factors considerations in helmet design and for 
risk assessments in Navy air operations, will be 
extended to include other (e.g., +Gz) acceleration vec- 
tors which are other important elements of the Navy 
aircrew environment. 



severed blood vessels. In this experimental procedure, 
the proximal and distal ends of a severed vessel are 
averted over specially designed rings, and then bound 
together using a vascular graft sleeve which shrinks at 
body temperature to hold the vascular ends tightly 
together. The anastomosis instruments and supplies 
will be packaged into a small, easily carried emergency 
kit which will be usable, shipboard or in the field, by 
medical personnel without specialized vascular surgical 
training. 



sailor's ship assignment, port visits made by all Navy 
ships, and the diseases experienced following these vis- 
its. Notably, all Navy and Marine Corps personnel who 
develop seropositivity for the Human Immunodefi- 
ciency Virus (HIV) are included in this database, as is a 
complete history of the clinical course of every HIV 
infection. NHRC's database provides to Navy medical 
planners essential information on sailor's risks of incur- 
ring HIV infection, other sexually transmitted diseases, 
and other infectious diseases at every foreign port 
visited by Navy and Marine Corps forces. 



For additional information on these or other medical 
R&D projects, contact NMRDC Code 40 at Commer- 
cial (202) 295-1468 or Autovon 295-1468, 



November-December 1989 



21 



Professional 



Dialytic Capabilities in 
the Operational Setting 



LCDR David J. Connito, MC, USNR HMC William J. Balko, USN 



Death was the usual result of the 
combat casualty with post- 
traumatic acute renal failure 
(PTARF) prior to the Korean War. 
Although accurate statistics of the 
incidence and mortality rate of this 
complication in World War II injuries 
are not available, it is generally quoted 



that between 68 and 90 percent in this 
selected group of patients died. (7,2) 

It must be realized that the majority 
of patients with PTARF are gravely ill 
irrespective of the development of 
acute renal failure. These casualties 
have multiple wounds, severe burns, 
and/ or crush injuries with rhabdo- 



The sorbent dialysis system 




myolysis. Protracted shock and sepsis 
from bacterial contamination contrib- 
ute to the high mortality rate and 
increase the risk of developing acute 
renal failure. Once renal failure de- 
velops, the complications associated 
with it, including hyperkalemia, 
volume overload, metabolic acidosis, 
and uremia, further increase the risk of 
death, (J) 

When a battlefield study of Korean 
War casualties revealed a significant 
number of acute renal failure cases, a 
center for treatment of such was estab- 
lished by the U.S. Army in Wonju, 
Korea in 1951.(4) With its institution, 
Teschan(5) and Smith(o") were able to 
report a decline in mortality rate of 
80-90 percent by field estimates to 53 
percent for patients treated at the renal 
center, and the successful management 
of acute renal failure with dialysis in 
the combat zone became a reality. 

As a consequence of the experience 
gained in the treatment of PTARF in 
the Korean War, dialysis support for 
these patients became more extensive 
during the Vietnam conflict, and a 
total of about 300 cases were seen at a 
number of specialty units. It was dur- 
ing this time, the U.S. Navy hospital 
ships, USS Sanctuary and USS 
Repose were brought into service. On 
board Sanctuary. 18 patients with 
PTARF were treated, and it was 
shown that with intensive dialysis, the 
mortality rate was reduced to 36 per- 
cent. The need for and efficacy of dia- 
lytic treatment in a shipboard setting 
thus became evident. 

NAVY MEDICINE 



PURIFIED 
WATER 



"1 



ARTIFICIAL 
KIDWEY 



-P r~ - -- 

-fr-iH 



-4 BLOOD FLOW 



DIALY5ATE 

CONCENTRATE I 



PROPORTIONER 



->• DRAIN 



DIALYSATE FLOW 



Diagram 1. Single-Pass System 



In 1986, CAPT T.G. Patel, Adviser 
to the Surgeon General for Nephrol- 
ogy, Naval Hospital, Portsmouth, 
addressed the need for hemodialysis 
capabilities on board the newly com- 
missioned hospital ship, USNS 
Mercy. He stressed that with an 80-bed 
intensive care unit and a total capacity 
of 1,000 hospital beds, Mercy required 
acute hemodialysis capabilities in 
order to provide maximal medical 
support. 

It was readily apparent that the 
shipboard dialysis unit would be very 
different from those in the community 
setting. Generally, outpatient dialysis 
centers use stationary hemodialysis 
machines that use what is described as 
the single-pass system (Diagram I). 
The large quantities of ultrapure water 
necessary for this type of system is 
derived from a water purification sys- 
tem that usually is an integral part of 
the dialysis facility. 

A typical 4-hour dialysis treatment 
for a single patient consumes about 
120 liters (32 gallons) of this ultrapure 
water. Clearly, the quantities of water 
necessary to treat multiple patients 
three to four times per week would not 



be available in a shipboard setting. 
Furthermore, since stationary hemo- 
dialysis machines are large and diffi- 
cult to move, a central location amidst 
the complex of wards, laboratories, 
and operating rooms, yet near the 
intensive care unit, would have to be 
created. Lastly, a machine that would 
tolerate the motion of a ship and not 
require extensive training on the part 
of the operator would have to be 
selected. 

All of the aforementioned problems 
were resolved with the selection of the 
sorbent dialysis system. As a fully inte- 
grated, portable unit, it incorporates 
all the accessories necessary for a com- 
pletely independent dialysis treatment, 
requiring only 6 liters of potable water 
that need not be further purified (Dia- 
gram 2). It uses standard dialysis mem- 
branes while removing metabolic 
waste with a sorbent cartridge. With 
this "mobile" system, the need for a 
stationary hemodialysis unit was alle- 
viated. 

The "operational" need for techni- 
cians proficient in all the functions and 
aspects of hemodialysis on board 
Mercy and Comfort is fulfilled by the 



L-a 



r 



ARTIFICIAL 

KIDHEY 



It* 



-BLOOD FLOW 



A 

| MM | 

-»- |cAR TR>D 



GEJ 



^Td 



INFUSATE 



'RESEHVIOR 



DIALYSATE FLOW 

Diagram 2. Sorbent Dialysate Regenerating System 



Transplantation Technician (NEC- 
HM 8433) rating. Training is provided 
at the Navy's four major teaching 
hospitals, In a 6-month program, a 
general duty corpsman can become 
thoroughly trained in the complexities 
of hemodialysis. 

After it had been determined that 
acute hemodialysis could readily be 
performed aboard Comfort and 
Mercy using the sorbent system, in 
November 1988, a combined forces 
conference was held in Fort Detrick, 
MD. There, representatives of the 
Army, Air Force, and Navy were suc- 
cessful in standardizing all aspects of 
hemodialysis in the event of a mass 
mobilization. Again, the sorbent sys- 
tem met all the requirements and re- 
strictions imposed by such a diverse 
group with unique potential combat 
theatres. 

Hemodialysis is now operationally 
ready. Because of a concerted effort by 
the combined forces, casualties can 
now, in a forward area, receive acute 
dialytic support previously unavaila- 
ble outside of tertiary care or specialty 
centers. 

References 

1. BalchHH.MeroncyWH.SakoY: Obser- 
vations on surgical care of patients with post- 
traumatic renal insufficiency. Surg Gynecol 
Obstet 100:439^52, 1955. 

2. Darmandy EM, Siddons AHM, Corson 
TC, et ah Traumatic uremia: Report of eight 
cases. Lancet 28:809-812, 1944. 

3. Butkus DE: Post-lraumatic acute renal 
failure in combat casualties: A historical review. 
Mitii Med 149:1)7-124, 1984. 

4. Howard JM (ed): Post-traumatic renal 
insufficiency, in Battle Casualties in Korea, 
Army Medical Service Graduate School, Walter 
Reed Army Medical Center, Washington, DC. 
1956. vol IV. 

5. Teschan PE, Post RS, Smith LH, et al: 
Post-traumatic renal insufficiency in military 
casualties. 1: Clinical characteristics. Am J Med 
18:172-186, 1955. 

6. Smith LH Jr. Post RS. Teschan PE.etal: 
Post-lraumalic renal insufficiency in military 
casualties. II: Management use of an artificial 
kidney, prognosis. Am J Med 18:187-198, 
1955. □ 



Dr. Connito and H MC Balko are assigned to 
the Nephrology Division. Naval Hospital, 
Portsmouth, VA 23708-5000. 



November-December 1989 



23 



Metal Fume Fever 



LT Charles Armstrong, MC, USNR 
LCDR Timothy D. Almquist, MC, USNR 



Metal fume fever is an acute self-limited syndrome 
consisting predominately of fever and respi- 
ratory symptoms that occur following exposure 
to freshly formed oxidized metal fumes. Originally de- 
scribed in 1822,(7) this condition has been reported in a 
variety of industrial settings and has been associated with 
several different metals. Many colorful and descriptive 
names have been used including brass chills, zinc chills, 
welder's ague, Monday morning fever, and foundry fever. 
The following illustrative cases were seen between March 
and October 1988 in the emergency department (ED) of 
Naval Hospital, San Diego. 

Case 1: A 25-year-old MM2 presented to the ED com- 
plaining of a 2-hour history of a dry nonproductive cough, 
shortness of breath, fever, chills, headache, and muscle 
aches. He denied nausea, vomiting, neck stiffness, rash, or 
any odd taste. The patient worked as a welder and stated 
that he had welded galvanized material (iron or steel 
coated with zinc to retard oxidation) for the first time that 
day, and stated that he was not wearing a respirator as he 
usually did. Past medical history was noncontributory. 
Physical examination was significant for a well-developed 
anxious white male in mild distress. Vital signs were: 
temperature 102.2°, pulse 100 and regular, RR 18, and BP 
126/80. HEENT examination was within normal limits. 
Lungs were clear to auscultation without wheezing or 
rales. Cardiovascular exam was normal. Chest X-ray was 
normal without infiltrates. Laboratory analysis revealed a 
leukocyte count of 1 2,200/ mm3 with 14 percent band 
forms. A cutaneous pulse oximeter revealed greater than 
97 percent oxygen saturation. The patient was treated with 
oxygen at 2 1/min via nasal cannula. He felt significantly 
improved after 2 hours of observation in the ED and was 
discharged to home with recommendations for bedrest and 
ibuprofen to be taken orally as needed for myalgia. 

Case 2: A 31 -year-old MM1 presented to the ED com- 
plaining of a 12-hour history of shortness of breath, a 
burning sensation in his chest, and a metallic taste. The 
patient had been welding galvanized material the previous 
day. The symptoms began approximately 4 hours after he 
had stopped welding. He denied cough, headache, muscle 
aches, nausea, or vomiting. Past medical history was sig- 
nificant for a remote history of asthma as a child, with no 
symptoms after age 5. Physical examination was signifi- 



cant for a well-developed white male who appeared in no 
distress. Vital signs were: temperature 99.3°, pulse 80, RR 
20, and BP 146/80. HEENT exam showed mild bilateral 
conjunctival hyperemia. Lungs were clear to auscultation 
without wheezing. Heart sounds were normal. Chest X-ray 
was unremarkable. EKG revealed normal sinus rhythm 
without acute ST changes. ABG showed pH 7.39, pC02 
45, p02 103, CO 1.3. The leukocyte count was 8,900/ mm3 
and a differential count was not performed. The patient 
was treated with bedrest, an anti-inflammatory agent, and 
reassurance. 

Clinical Presentation 

Metal fume fever is a self-limited illness, with nonspe- 
cific symptoms, easily misdiagnosed as a viral process. The 
symptoms are fever (usually mildly elevated but may reach 
104°), chills, dry cough, subjective dyspnea, chest tight- 
ness, and myalgia. Frequent associated symptoms are 
thirst, nausea, vomiting, and often a metallic or sweet 
taste. The physical exam may reveal wheezing or rales, 
although this does not appear to be a predominant feature 
in most described cases of metal fume fever. 

The symptoms generally resolve after 24-48 hours after 
exposure, followed by complete recovery. In cases of 
chronic exposure a degree of tolerance builds up which is 
quickly lost after several days of nonexposure. Reappear- 
ance of symptoms may occur following reexposure, hence 
the name "Monday morning fever." There are no known 
chronic sequelae of this disorder, and no symptoms of 
pulmonary fibrosis or pneumoconiosis have been 
described. (6) 

Acute cadmium pneumonitis is a disorder distinct from 
metal fume fever and one that is potentially fatal. How- 
ever, both metal fume fever and cadmium pneumonitis 
may have similar presentations, and differentiation may 
depend solely upon an accurate exposure history. (J) 

Pathogenesis 

Acute inhalation of freshly formed oxides of specific 
metals, as produced by welding or torch cutting, is the 
precipitating event of metal fume fever. The symptoms 
characteristically do not occur immediately upon expo- 
sure, but rather after a latency period of 3-6 hours. Most 
cases develop with exposure to zinc oxide in a poorly 



24 



NAVY MEDICINE 



ventilated environment, most commonly after welding gal- 
vanized iron, but various other metals including cadmium, 
chromium, lead, copper, nickel, magnesium, manganese, 
antimony, and tin(2) have been implicated. Zinc oxide is 
formed when zinc or one of its alloys is heated within an 
oxidizing atmosphere to its boiling point of 907° C, result- 
ing in particles ranging in size from 0.2 to 1 micron {ft ). 
Particles of this size, if inhaled, may reach the periphery of 
the lung and affect alveolar function. Concentrations of 
zinc oxide as low as 5 mg/ m3 have produced symptoms. (2) 

The exact mechanism by which metal fume fever is 
caused is unknown, but theories abound. An immune 
complex reaction to the inhaled metal oxide fumes is the 
most widely accepted theory according to Mueller and 
Seger. McCord(4) suggested that the inhaled particles 
result in inflammation and damage of respiratory tract 
tissue, and the damaged tissue and metal oxide particles 
form an antigen which leads to production of an antigen- 
antibody complex. Anti-antibody may be formed against 
this immune complex and provides a degree of immunity 
to repeated exposure. This theory is attractive because it 
explains the short-term tolerance which develops in 
workers chronically exposed to zinc oxide fumes and the 
exacerbation of symptoms after periods of no exposure. 

Other theories include a metal fume induced release of 
endogenous pyrogen, (J) and the production of a type of 
hypersensitivity pneumonitis. Vogelmeier et al.(6) per- 
formed bronchoscopy and bronchoalveolar lavage in a 
subject with a history of metal fume fever 1 day after 
challenge with zinc oxide fumes and found a tenfold 
increase in bronchoalveolar lavage leukocyte count with a 
marked increase in polymorphonuclear forms. Repeat 
bronchoscopy 7 weeks later showed a normal cell count. 
These authors state that metal fume fever resembles a 
hypersensitivity pneumonitis but is atypical, as a lympho- 
cytosis is usually found in lavage specimens. 

Investigative Studies 

Metal fume fever is a diagnosis made by occupational 
history, as the laboratory features are not diagnostic. 
There is usually a mild leukocytosis (12,000-16,000/ mm3) 
with a left shift. Lactic dehydrogenase may be moderately 
elevated with the third (pulmonary) fraction accounting 
for the elevation. Serum and urinary levels of specific 
heavy metals are usually elevated, but typically are not 
immediately available and have not been shown to corre- 
late with degree of symptoms. (7) 

The chest X-ray is usually normal, although transient 
infiltrates have been reported ,(8) Mild hypoxemia may be 
apparent on arterial blood gas analysis. Pulmonary func- 
tion tests may be acutely impaired (decreased PEFR, FEV, 
FVC), but return to normal values as symptoms recede. 
Malo et al.(9) precipitated symptoms of metal fume fever 
in two workers with a history of the illness by exposing 
them to zinc oxide fumes, and found significant reductions 
in FEV1 (80 percent of predicted) and FEV1/FVC (60 



percent of predicted) with gradual return to normal values 
over 24 hours. 

Treatment 

Treatment is supportive and consists of rest, analgesics, 
and antipyretics as well as education as to the preventable 
nature of this illness. Milk and antacids are a layman's 
treatment for exposure to metal fumes('O) and may pro- 
vide symptomatic relief for occasional gastrointestinal irri- 
tation. Corticosteroids are occasionally recommended to 
reduce the inflammatory response in the rare more 
advanced cases, but no controlled trials have investigated 
this therapeutic option. Antibiotics likewise are of no 
proven benefit. Bronchodilation therapy should be used if 
wheezing or reduction of PEFR is present. 

Several studies have documented elevated zinc(fj) and 
copper levels, but chelation is not considered necessary 
and is not recommended. In general, the most appreciated 
treatment is reassurance that the symptoms are brief in 
nature and complete recovery can be expected. 

Conclusion 

Two cases of metal fume fever caused by the welding of 
galvanized metal have been described. These cases proba- 
bly would have been attributed to a viral etiology if an 
occupational history had not been taken. In the event of 
exhaust ventilation or respirator malfunction, or poor 
work practices, a welder may receive significant exposure 
and experience symptoms. Our active duty population is 
subjected to a host of potential chemical exposures on a 
daily basis, and this syndrome is but one example of poten- 
tial clinical sequelae to this exposure. 



References 

1. Mueller EJ, Seger DL: Metaf fume fever: A review. J Emerg Med 
2:271-274, 1985. 

2. Poisindex, Micromedex Inc. 1986-1987, vol 51. 

3. Barnholl S, Rosenstock L: Cadmium chemical pneumonitis. Chesi 
86:789-791. 1984. 

4. McCord CP: Metal fume fever as an immunological disease. Indus 
Med Surg 29:101-107, 1960. 

5. Pernis B. Vigliani EC, Cavagna G, Fimslli M: Endogenous pyro- 
gen in the pathogenesis of zinc fume fever. Med Lav 51:579-586, I960. 

6. Vogelmeier C. Konig G. Bencze K. Fruhmann G: Pulmonary 
involvement in zinc fume fever. Chest 92(5):946-948, 1987. 

7. Noel NE, Ruthman JC: Elevated serum zinc levels in metal fume 
fever. Am J Emerg Med 6(6):609-610, 1988. 

8. Dula DJ: Metal fume fever. J Am Coll Emerg Phy.s 7:448-450, 
1978. 

9. Malo J L, Cartier A: Occupational asthma due to fumes of galvan- 
ized metal. Chest 92(2):375-377, 1987. 

10. Anseline P: Zinc fume fever. Med J Ausl 2:316-318. 1972. □ 



Dr. Armstrong is a senior resident in the Emergency Department, 
Naval Hospital, San Diego, CA 92134. Dr. ASmquist is a staff physician 
in the Emergency Department at the same facility. 



November-December 1989 



25 



In Memoriam 




RADM 
Lucas 



RADM John R. Lukas, MCfRet.)died at Naval Hospital, 
Oakland on 22 Oct 1989. Born 24 Sept 1925 in Mercer, PA, 
Dr. Lukas' Navy career spanned 40 years. 

He received his B.A. degree in chemistry in 1950 at 
Westminster College, New Wilmington, PA, Doctor of 
Medicine in 1954 from the University of Pittsburgh, and 
completed his internship and residency in obstetrics and 
gynecology in 1958 at Naval Hospital, Oakland. 

RADM Lukas became a naval aviator in 1946, a flight 
surgeon in 1959, and held positions as medical officer or 
commanding officer at various military hospitals in Cali- 
fornia, Virginia, Texas, Florida, Guam, and Morocco. In 
1978, he was selected as rear admiral and later assumed 
duties as Inspector General, Medical, Bureau of Medicine 
and Surgery, and Special Assistant to the Surgeon General 
for Medical Readiness. He retired from the Navy in 1984 
and resided at his home in Pebble Beach, CA, until his 
death. 



HMCM Stephen W, Brown (Ret.) died of cancer 26 Oct 
1989 at the National Naval Medical Center. Brown served 
as the Force Master Chief Petty Officer of the Medical 
Department from February 1981 to 1985, 

During his 34 years in the Navy, Brown served in a 
variety of assignments, including the 1st Marine Division 
in Korea; L'SS Philippine Sea (CVA-47); Naval Hospital, 
San Diego, CA; Naval Hospital, Oakland, CA; 3rd Medi- 
cal Battalion, Okinawa; and Command Master Chief, 
Oakland. Perhaps his most notable duty, however, was as 
the first enlisted Director of the Hospital Corps at the 
Bureau of Medicine and Surgery. 

Brown was named Director of the Hospital Corps, a 
position normally held by a Navy captain, 17 June 1979. In 



making the announcement, VADM W.P. Arentzen, Navy 
Surgeon General, said, "Master Chief Brown, with 27 
years' service and a master's degree in public administra- 
tion, is a fine example of the type of senior enlisted person- 
nel we have in the Navy today. Highly educated, with years 
of practical experience and great leadership qualities, he is 
an ideal man for the job." Brown directed the 24,000 men 
and women of the Hospital Corps for the next 2 years 
before his selection as Force Master Chief Petty Officer of 
the Medical Department. 

As Force Master Chief, Brown served as the senior 
enlisted advisor to Navy Surgeon General VADM J. Wil- 
liam Cox. He traveled throughout the Navy, meeting with 
enlisted hospital corpsmen, listening to their comments 
and advising the Surgeon General on enlisted medical 
matters. 

Brown held lifetime college-level teaching credentials 
from California and was a registered sanitarian in Oregon. 
He earned his bachelor's and master's degrees in public 
administration from Golden State University, He was a 
graduate of Hospital Corps General Surgery and Operat- 
ing Room School and the Preventive Medicine Technician 
School. 

Earlier this year, the Navy established the "HMCM 
Stephen W. Brown Preventive Medicine Technician of the 
Year Award" to recognize individual PMTs for their "sus- 
tained professional excellence and significant contribu- 
tions to the Navy's Occupational Health and Preventive 
Medicine Program," 

Brown retired from the Navy in 1986. He was buried 
with full military honors 30 Oct 1989 at the National 
Cemetery, Quantico, VA. 

—Sonny Auld. Public Affairs Office. NNMC Bethesda, MD. 




HMCM 
Brown 



26 



NAVY MEDICINE 



INDEX 

Vol. 80, Nos. 1-6, January-December 1989 



ALABAMA'S last stand 5:24 
Aimquist, T.D., LCDR, MC, USNR, 

metal fume fever 6:24 
AMA House of Delegates, 1989 meeting 

5:21 
Amberson, J.M., CAPT, MC (Ret.) 
in memoriam 1-2:32 
Operation Passage to Freedom (17 Aug 
1954 to 19 May 1955) 1-2:26 
Anderson, M.H., CDR, DC, gas plasma 
sterilization: innovation in prac- 
tice 5:9 
Anthropology, medical 6:13 
Armstrong, C, LT, MC, USNR, metal 

fume fever 6:24 
Arp, M.P., HMC, letter to editor 1-2:40 
Awards 

Smith, A.M., CAPT, MC, USNR-R, re- 
ceives Distinguished Author Award 
1-2:40 
Stephen W. Brown Award established 

1-2:39 
Thomas, D.E., DTI, COMNAVMED- 
COM 1989 Sailor of the Year 4:4 
Aviation 

new prediction model relates helmet 
weight to aircrew neck injury risks 
6:21 
nonaircrew frequent flier training 1-2:17 

BABY, miracle, E.M. Gustafson 4:6 
Balko, W.J., HMC, dialytic capabilities in 

the operational setting 6:22 
Beaudoin, R.P., LT, MSC, total quality 

management: mandate for change 

6:10 
Begasse, T., J02, miracle baby 1 year later 

4:6 
Betts, L.S., LCDR, MC, USNR, from 

fortress to factory: occupational 

medicine aboard USS Kitty Hawk 

3:24 



NOTE: Figures indicate the issue and page in 
Volume 80 of Navy Medicine. Forexample, 5:24 
shows the article may be found in issue No. 5 
(September-October), page 24. Issues No. 1 and 
2 were combined (January-February; March- 
April). 



Blood 
type A and type B red blood cells can 
now be converted to type O 4:29 

Boccuzzi, S.J., LT, NC, USNR, food 
handlers: a potential high risk group 
for hypercholesterolemia 1-2:37 

Brown, F.C., LCDR, MSC, military med- 
icine in action 3:4 

Brown, S.W., HMCM (Ret.) 
in memoriam 6:26 

preventive medicine technician award 
established 1-2:39 

Bruzek-Kohler, CM., LCDR, NC, hos- 
pital corpsmen will be even better 3: 12 

BUMED (Bureau of Medicine and Sur- 
gery), welcome back 4:10 

Butler, F., CDR, MC, Everest adven- 
ture 3:2, 5:4 

CHANGE of command, NAVMEDCOM 

5:3 
Cholera, conquest of 3:20 
Cholesterol 

hypercholesterolemia in food handlers 
" 1-2:37 
Cilento, B., Sr., CAPT, MC 5:7 
Circles, Quality 5:22 

Class, J.S., LT, MSC, from fortress to 
factory: occupational medicine 
aboard USS Kitty Hawk 3:24 
Clegg, M.C., RADM, DC, 29th Chief of 

Dental Corps [-2:39 
Combat wounds 

new collagen gel for 5:11 
surgery of mortar shell in chest 6:6 
COMNAVMEDCOM 
change of command 5:3 
back to BUMED 4:8, 10 
Sailor of the Year, 1989, DTI 
Thomas 4:4 
Computerized system can predict health 
risks for deployed sailors and marines 
6:21 
Condlin, C, HMCS, food handlers: a 
potential high risk group for hyper- 
cholesterolemia 1-2:37 
Connito, D.J., LCDR, MC, USNR, dia- 
lytic capabilities in the operational 
setting 6:22 
Conquest of cholera 3:20 



Cough, when it doesn't get better 4:24 
Crowl, P.E., CW04/PA-C, letter to editor 

1-2:40 
Cuba, Santiago, 1898, testing the enemy 

4:20 
Custis, S., LCDR, MSC, Management 

Assist Teams (MAT's) 3:22 

DECOMMER, P.R., CW04/ PA-C, letter 
to editor 1-2:40 

DEET, insect repellent that really works 
3:19 

Dental Corps, Navy 
Clegg, M.C., RADM, DC, 29th Chief 

of Dental Corps 1-2:39 
Shaffer, R., RADM, DC, retires 1-2:7 

Dialytic capabilities in the operational 
setting 6:22 

Dinsmore, II. H„ CAPT, MC (Ret.) 6:6 

Disease Vector Ecology and Control Cen- 
ter (DVECC), 40 years of medical 
entomology 4:16 

Distinguished Author Award 1-2:40 

Douglas, R.A. 
Alabama's last stand 5:24 
treating the enemy, Santiago, Cuba, 
1898 4:20 

Drugs 

rTPA in the emergency therapy of acute 
transmural myocardial infarction 
5:28 

Dunn, J., CDR, MC(FS), USNR, from 
fortress to factory: occupational med- 
icine aboard USS Kitty Hawk 3:24 

DVECC (Navy Disease Vector Ecology 
and Control Center) 4:16 

EDUCATION (see also Training) 
Graduate Medical Education 3:18 
HSETC (Naval Health Sciences Educa- 
tion and Training Command) 3:6 
Edward Rhodes Stitt Library 3:11 
Electromagnetic radiation warming de- 
vices 5:1 1 
Elwood, S. W., LT, transportation of litter 

patients in USS Missouri 6:17 
Emergency therapy of acute transmural 

myocardial infarction, rTPA 5:28 
Entomology, medical, 40 years of 4:16 
Everest adventure 3:2, 5:4 



November-December 1989 



27 



FAMILY services. Navy, and the Stark 

incident 1-2:20 
Federal Healthcare Innovation Network 

(FHIN) 1-2:10 
Fliers 
new prediction model relates helmet 

weight to aircrew neck injury risks 

6:21 
nonaircrew frequent flier training 1-2:17 
Flight surgeon's heart and hands go out to 

villagers 6:2 
Food handlers: a potential high risk group 

for hypercholesterolemia 1-2:37 
From fortress to factory: occupational 

medicine aboard USS Kitty Hawk 

3:24 

GAS plasma sterilization: innovation in 
practice 5:9 

Gildea, K.A., Everest adventure 3:2, 5:4 

Graduate Medical Education (GME): The 
cornerstone of Navy medicine 3:18 

Grant, B.H., medical anthropology: a pro- 
spective role in Navy medicine 6:13 

Grogan, R.A., HMC, letter to editor 
1-2:40 

Gustafson, E.W,, is miracle baby 4:6 

HARRIS, D„ Jr., CDR, MC, Everest 

adventure 3:2, 5:4 
Health care innovation 
gas plasma sterilization 5:9 
the challenge of change 1-2:14 
What can we expect? 1-2:10 
Heart, acute transmural myocardial in- 
farction 5:28 
Heath, D.K.. HMC(AC), letter to editor 

1-2:40 
Helmets 
new prediction model relates helmet 
weight to aircrew neck injury risks 
6:21 
Hepatitis B in Navy personnel 5:11 
Herman, J.K. 
conquest of cholera 3:20 
interview with RADM R. Shaffer, DC 

1-2:7 
letters to 1-2:40, 4:28 
Navy medicine and tetanus 4:22 
welcome back BUMED 4:10 
Hippocratic oath's secrecy clause: a view 

from the courts 1-2:23 
History 

battle between USS Kearsarge and CSS 

Alabama 5:24 
BUMED, welcome back 4:10 
cholera, conquest of 3:20 
Navy medicine and tetanus 4:22 
Santiago, Cuba, 1B98, treating the 

enemy 4:20 
Squibb, E.R., surgeon 5:26 



History (con.) 

Vietnam 
Operation Passage to Freedom (17 
Aug 1954 to 19 May 1955) 1-2:26, 
33 
surgery of mortar shell in chest 6:6 
HIV-1 infection inactivates an important 

receptor on T-lymphocytes 4:29 
Honduras 
flight surgeon's heart and hands go out 
to villagers 6:2 
Hood, T., CAPT, Management Assist 

Teams (MAT's) 3:22 
Hospital Corps, Navy, training 3:12 
HSETC (Naval Health Sciences Educa- 
tion and Training Command) 3:6 
Hubbard, J.R., RADM, DC, USNR, let- 
ter to editor 1-2:40 
Hypercholesterolemia in food handlers 
1-2:37 

ICE vests used to cool Persian Gulf sailors 
4:29 

In memoriam 
Amberson, J.M., CAPT, MC (Ret.) 

1-2:32 
Brown, S.W.. HMCM (Ret.) 6:26 
LeTourneau, D.J., CAPT, MC 4:28 
Lukas, J.R., RADM, MC (Ret.) 6:26 

Innovation in Navy medicine 
gas plasma sterilization 5:9 
the challenge of change 1-2:14 
What can we expect? 1-2:10 

Interview 

Shaffer. R., RADM, DC, retires 1-2:7 

JUDSON. P.L.. CAPT. MC (Ret.), rTPA 
in the emergency therapy of acute 
transmural myocardial infarction 
5:28 

KEARSARGE and Alabama, 18645:24 
Kemp. D.G., CAPT, MC, report from the 

1989 annual meeting of A MA House 

of Delegates 5:21 
Kitty Hawk, occupational medicine 3:24 
Kootte, A.F., Navy family services and the 

Stark incident 1-2:20 
Krieger, D,, LT, MSC, innovation in Navy 

medicine: What can we expect? 1-2: 10 

LAMBERT, W.J.. Jr., CDR, MSC 
innovation in Navy medicine: What can 

we expect? 1-2:10 
total quality management: mandate for 
change 6:10 

Lamdin, J.M., CAPT. MSC, letter to 
editor 4:28 

Lee, K., LCDR, MC, USNR, food han- 
dlers: a potential high risk group for 
hypercholesterolemia 1-2:37 



Legal 
Hippocratic oath's secrecy clause: a 
view from the courts 1-2:23 

LeTourneau, D.J., CAPT, MC, in memo- 
riam 4:28 

Let's get realistic about medical prepared- 
ness for war 5:12 

Letters to editor 1-2:40, 4:28 

Library, Edward Rhodes Stitt 3:11 

Like father, like son 5:7 

Litter patients in USS Missouri, trans- 
portation of 6:17 

Lukas, J.R.. RADM, MC (Ret.), in 
memoriam 6:26 

MANAGEMENT 

Management Assist Teams (MAT's) 

3:22 
Quality Circles 5:22 
total quality 6: 10 

MEDCAP's (Medical Civil Action Pro- 
grams) 1-2:4. 3:4 

Medical anthropology: a prospective role 
in Navy medicine 6:13 

Medical Civil Action Programs (MED- 
CAP's) 1-2:4, 3:4 

Medical database predicts health risks for 
deployed sailors and marines 6:21 

Medical Department, Navy, reorganiza- 
tion 4:8, 10 

Medical entomology, 40 years of 4:16 

Meetings 
AMA House of Delegates. 1989 5:21 
AMSUS, 1989 1-2:39 

Metal fume fever 6:24 

Microwave oven, gas plasma sterilization: 
innovation in practice 5:9 

Military medicine in action 3:4 

Miracle baby I year later 4:6 

Missouri, transportation of litter patients 
in 6:17 

Moe, R.C., CAPT. DC, Quality Circles 
5:22 

Moore, V.J., CAPT, MC, USNR-R, the 
Hippocratic oath's secrecy clause: a 
view from the courts 1-2:23 

Mortar shell lodged in chest 6:6 

Mt. Everest adventure 3:2, 5:4 

Myocardial infarction, transmural, acute 
5:28 

NAVAL Health Sciences Education and 

Training Command (HSETC) 3:6 
Naval Medical Research Unit No. 2 De- 
tachment, Jakarta, Indonesia, estab- 
lishes clinical research 1CU 5:11 
NAVMEDCOM 

change of command 5:3 
back to BUMED 4:8, 10 
Sailor of the Year, 1989, DTI 
Thomas 4:4 



28 



NAVY MEDICINE 



Navy Disease Vector Ecology and Control 

Center (DVECC), 40 years of medical 

entomology 4:16 
Navy Environmental Health Center. 

(NAVENVIRHLTHCEN) dedicates 

new facility 6:5 
Navy family services and the Stark inci- 
dent 1-2:20 
Navy Medical Department reorganization 

4:8, 10 
Navy Medical Research and Development 

Command (NMRDC), highlights 

3:19,4:29, 5:11, 6:21 
Navy medicine 
and tetanus 4:22 
innovation in 1-2: 10 
the challenge of change 1-2:14 
Neck injury 

new prediction model relates helmet 

weight to aircrew neck injury risks 

6:21 
NMRDC highlights 3:19, 4:29, 5:11, 6:21 
Noland, L.. recognizing our best 4:4 
Nonaircrew frequent flier training 1-2:17 
Norcross, M.C., LT, MC, transportation 

of litter patients in USS Missouri 6: 17 

OATLEY, T. W., COL, USAF, MSC. the 
challenge of change 1-2:14 

Occupational medicine aboard USS Kilty 

Hawk 3:24 
Okinawa, like father, like son 5:7 
Operation Passage to Freedom (17 Aug 

1954 to 19 May 1955) 1-2:26, 33 

PAYOFFS of Navy Medicine 
a quest for purity: Surgeon Edward R. 

Squibb 5:26 
conquest of cholera 3:20 
Navy medicine and tetanus 4:22 
Pediatrics 

miracle baby. E.M. Gustafson 4:6 
Philippines 

military medicine in action 3:4 
Phillips, R.A., CAPT, MC, cholera re- 
search 3:20 
Plasma, gas, sterilization 5:9 
Preventive medicine technician award 
named in honor of HMCM S.W. 
Brown (Ret.) 1-2:39 
Project Handclasp 1-2:4 

QUALITY Circles 5:22 

REDMOND, D.M., reminiscences of 

Passage to Freedom 1-2:33 
Reinert. C.G.. CAPT, MC, Graduate 

Medical Education: The cornerstone 

of Navy medicine 3:18 
Reminiscences of Passage to Freedom 

1-2:33 



Reorganization, Navy Medical Depart- 
ment 4:8, 10 
Research 
ICU established in Indonesia 5:11 
NMRDC highlights 3:19, 4:29, 5:11, 
6:21 
Rickey. T.L., LCDR, MSC, nonaircrew 

frequent flier training 1-2:17 
Ridout, J.A., DTC, USNR-R. a quest for 
purity: Surgeon Edward R. Squibb 
5:26 
rTPA in the emergency therapy of acute 
transmural myocardial infarction 
5:28 

SAILOR of the Year, 1989, COMNAV- 

MEDCOM, DTI Thomas 4:4 
Samuelson, H., JOl, USNR, U.S. -Thai 
armed forces bring medical aid to 
villagers 1-2:4 
Santiago, Cuba. 1898, treating the enemy 

4:20 
Savage, R.W., LCDR, MC.food handlers: 
a potential high risk group for hyper- 
cholesterolemia 1-2:37 
Savage, S.E., LCPL, USMC, night sur- 
geon's heart and hands go out to 
villagers 6:2 
Schinski, V.D., CAPT, MSC 

hospital corpsmen will be even better 

3:12 
we teach caring 3:6 
Sears, H.J.T.. RADM, MC 
farewell 4:3 

innovation: the application of brain- 
power 1-2:3 
retires 5:3 
Sen, R.P., LCDR, MC, USNR, when the 

cough doesn't get better 4:24 
Shaffer. R., RADM, DC, retires 1-2:7 
Ships 

USS Kearsarge and Alabama, 1864 

5:24 
USS Kitty Hawk, occupational medi- 
cine 3:24 
USS Missouri, transportation of litter 

patients in 6:17 
USS Okinawa, like father, like son 5:7 
USS Stark and Navy family services 
1-2:20 
Sibbel, T,, ,I03. like father, like son 5:7 
Smith. A.M.. CAPT, MC, USNR-R 
let's get realistic about medical pre- 
paredness for war 5:12 
receives Distinguish Author Award 
1-2:40 
Smith. J.W.. CDR, MC, transportation of 

litter patients in USS Missouri 6:17 
Squibb, E.R., surgeon 5:26 
Stark incident and Navy familv services 
1-2:20 



Stephen W. Brown Award established 

1-2:39 
Sterilization, gas plasma 5:9 
Stitt Library, 3:11 
Submarines 

white light in operation rooms 3:19 
Surgery of mortar shell in chest 6:6 

TETANUS and Navy medicine 4:22 
Thailand 

U.S. -Thai armed forces bring medical 
aid to villagers 1-2:4 
Thomas, D.E., DTI, COMNAVMED- 

COM 1989 Sailor of the Year 4:4 
Thyroid hormones increase during pro- 
longed cold exposures 3:19 
Total quality management (TQM): man- 
date for change 6:10 
Training 
Exercise Cobra Gold '88 1-2:4 
Graduate Medical Education 3:18 
hospital corpsmen 3:12 
HSETC 3:6 

war, medical preparedness for 5:12 
water survival 1-2:17 
Transportation of litter patients in USS 
Missouri 6: 1 7 

URUCHURTU, R., LT MC 6:2 
U.S.-Thai armed forces bring medical aid 
to villagers 1-2:4 

VASCULAR anastomoses without 

sutures? 6:21 
Vietnam 
Operation Passage to Freedom (17 
Aug 1954 to 19 May 1955) 1-2:26, 33 
surgery of mortar shell lodged in chest 
6:6 

WAR, medical preparedness for 5:12 

Warming devices, electromagnetic radia- 
tion 5:11 

Water survival training 1-2:17 

Welcome back BUM ED 4:10 

We teach caring 3:6 

Wickham, C.W., CAPT, MC(FS), from 
fortress to factory: occupational 
medicine aboard USS Kitty Hawk 
3:24 

Wooster, M.T., LCDR, MSC, 40 years of 
Navy medical entomology 4:16 

Wound dressing, combat, new collagen 
gel for 5:1 1 

X-RAY of mortar shell lodged in chest 6:6 

Z1MBEL, J.A., VADM, MC 

BUMED: "Back to the Future" 4:1 
change of command 5:3 
innovation is for everyone 1-2:1 



November-December 1989 



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